Basic Information
| Provider Information | |||||||||
| NPI: | 1528730546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERROS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TERROS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6023027925 | ||||||||
| Practice Location | |||||||||
| Address1: | 3531 N MOORE ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 9286792198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEPPER | ||||||||
| AuthorizedOfficialFirstName: | KAREN HOFFMAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6026856000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TERROS INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 101533 | 05 | AZ | MEDICAID |